Attachment B - Vendor Data Sheet.pdf
PDF 122 KB Posted
- Solicitation number
- RFP-127377
- Issued by
- Virginia
About this file
This is a Vendor Data Sheet attachment used by the Virginia Department of Labor and Industry as part of their solicitation process for medical examination services for VOSH and Boiler employees. The document establishes mandatory vendor qualification requirements that bidders must complete and submit to avoid having their bids deemed nonresponsive. Vendors must demonstrate capability and capacity to fully satisfy all contractual requirements and provide a primary contact name and phone number. Additionally, vendors must document their years in business providing the requested type of service, supply their eVA Vendor ID or DUNS Number, and provide detailed information on at least four current or recent accounts—either commercial or governmental—that they are servicing or have serviced with similar goods or services.
For each reference account listed, vendors must include the company name, contact person, phone and fax numbers, project description, dates of service, and dollar value of the work performed. Vendors must certify the accuracy of all information provided by signing and dating the completed form. The form also includes conflict-of-interest certification language requiring vendors to confirm they have not received compensation from any interested firm and that no immediate family members have received compensation, salary, or wages exceeding $5,000 from any interested firm. This form was originally established in September 1998 and is used by the Virginia Department of General Services and Division of Purchases and Supply to verify bidder experience and check references prior to contract award.
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| Attachment C - State Corporation Commission Form.pdf | ||
| Attachment A - VOSH Program Directive 08-005A.pdf |
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Text version
VENDOR DATA SHEET
Note: The following information is required as part of your response to this solicitation. Failure to complete and provide this sheet may result in finding your bid nonresponsive. (In the case of a two-step IFB, it may cause the proposal portion to be determined to be not acceptable.)
1. Qualification: The vendor must have the capability and capacity in all respects to satisfy fully all of the contractual requirements.
2. Vendor’s Primary Contact:
Name: __________________________________ Phone: _________________________
3. Years in Business: Indicate the length of time you have been in business providing this type of good or service:
__________ Years ________ Months
4. Vendor Information:
eVA Vendor ID or DUNS Number: ________________________________
5. Indicate below a listing of at least four (4) current or recent accounts, either commercial or governmental, that your company is servicing, has serviced, or has provided similar goods. Include the length of service and the name, address, and telephone number of the point of contact.
A. Company:_________________________________Contact: ____________________________________
Phone:(_____)______________________________ Fax: (_____)________________________________
Project:_____________________________________________________________________________
Dates of Service: _________________________________$ Value: _______________________
B. Company________________________________ Contact: ____________________________________
Phone:(_____)___________________________ Fax: (_____)_________________________________
Project:______________________________________________________________________________
Dates of Service: _________________________________$ Value: ________________________
C. Company:________________________________ Contact: ____________________________________
Phone:(_____)______________________________Fax:(_____)_________________________________
Project:______________________________________________________________________________
Dates of Service: _________________________________$ Value: ________________________
D. Company:_________________________________Contact: ____________________________________
Phone:(_____)______________________________Fax:(_____)_________________________________
Project:______________________________________________________________________________
Dates of Service: _________________________________$ Value: _______________________
I certify the accuracy of this information.
Signed: ____________________________________Title: ________________________________ Date: _______________
When used: This form is used as an attachment to a solicitation when the agency or institution wishes to check the bidder’s/offeror’s references or to verify the bidder’s/offeror’s experience.
| SEPTEMBER 1998 |
| DGS/DPS Support and Assistance |
| Electronic Procurement |
| a. Sponsoring a Joint Procurement: No state agency or institution may sponsor, conduct or administer a joint procurement without advance approval from the Director of the Division of Purchases and Supply. If a state agency or institution seeks to a... |
| a. Receipt. Bids shall be received until the date and time specified in the IFB. Bids are then publicly opened and read aloud. Late bids shall not be considered. Bid receipt deadlines and public openings scheduled during a period of suspended stat... |
| 7.5 Delete |
| Description of Item/Service |
| E. I certify that I have not received any compensation from any interested firm. No member of my immediate family has received compensation, salary or wages in excess of $5,000 from any interested firm. |
| Signature Date |
| E. I certify that I have not received any compensation from any interested firm. No member of my immediate family has received compensation, salary or wages in excess of $5,000 from any interested firm. |
| Signature Date |
| CHAPTER 12 |
| State Surplus Property |
| SURPLUS PROPERTY REPORT |
| Surplus computers and related equipment may be donated to public schools in the Commonwealth and Virginia charitable organizations granted 501(c) (3) status, and providing services to persons with disabilities, at-risk youths, or low-income families. ... |
| ANNEX 12-G |
| ANNEX 12-H |
| ANNEX 12-I |
| ANNEX 12-J |
| ANNEX 12-K |
| ANNEX 12-L |
| Annex 13-A |
| ELECTRONIC PROCUREMENT |
| I. Delete |
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